A nurse is caring for a client who has a chest tube that was inserted 4 days ago. Which of the following findings should the nurse report to the charge nurse?

Respiratory rate 16/min

Blood pressure 110/70 mm Hg

400 mL of drainage in the collection chamber within 4 hr

Fluctuation in the water seal chamber with respiration

Answer and Explanation

The Correct Answer is C

A. Respiratory rate 16/min is a normal finding. A respiratory rate of 16/min is within the expected range for adults, so it does not indicate a problem that requires immediate attention.

B. Blood pressure 110/70 mm Hg is within the normal range for blood pressure. This is an acceptable finding and does not require reporting to the charge nurse.

C. 400 mL of drainage in the collection chamber within 4 hr should be reported to the charge nurse. This is an excessive amount of drainage for a client with a chest tube. After the first few hours post-surgery, the drainage should decrease. Large amounts of drainage may indicate bleeding, and it is important to notify the charge nurse immediately to assess the situation further.

D. Fluctuation in the water seal chamber with respiration is a normal finding. It is expected for the water seal chamber to fluctuate with the client’s respirations, indicating that the chest tube is functioning properly and the system is not obstructed.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Instant coffee: Instant coffee generally contains more caffeine than brewed green tea or cola soft drinks. A typical 8 oz serving of instant coffee contains about 30–90 mg of caffeine.

B. Hot cocoa: This is correct. Hot cocoa contains the least amount of caffeine compared to the other options. An 8 oz serving typically contains around 5–10 mg of caffeine.

C. Brewed green tea: Brewed green tea typically contains more caffeine than hot cocoa, with an 8 oz serving containing around 30–50 mg of caffeine.

D. Cola soft drink: Cola soft drinks typically contain more caffeine than hot cocoa, with an 8 oz serving containing about 24–46 mg of caffeine.

A. Thrombocytopenia B. Dry cough C. Hypotension D. Hyperglycemia

Correct Answer is C

Explanation

A. Thrombocytopenia: Neither atenolol nor nitroglycerin is commonly associated with thrombocytopenia. This is not the primary concern when these two medications are used together.

B. Dry cough: A dry cough is a known side effect of ACE inhibitors (e.g., enalapril), but it is not commonly associated with atenolol or nitroglycerin.

C. Hypotension: Both atenolol (a beta-blocker) and nitroglycerin (a vasodilator) can lower blood pressure. When taken together, there is an increased risk of hypotension, especially when standing up quickly. The nurse should monitor the client for symptoms of low blood pressure such as dizziness, fainting, or lightheadedness.

D. Hyperglycemia: Atenolol may mask signs of hypoglycemia in clients with diabetes, but it does not directly cause hyperglycemia. Nitroglycerin is not typically associated with hyperglycemia either. Therefore, hyperglycemia is not a concern in this scenario.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client who has a chest tube that was inserted 4 days ago. Which of the following findings should the nurse report to the charge nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client about reducing dietary caffeine intake. The nurse should remind the client that 240 mL (8 oz) of which of the following beverages contains the least amount of caffeine?

Correct Answer is B

Explanation

A nurse is reviewing the medication administration record of a client who takes atenolol PO and applies a nitroglycerin transdermal patch daily. For which of the following interactions should the nurse monitor this client?

Correct Answer is C

Explanation

A nurse is caring for a client who is postoperative following abdominal surgery and has a wound evisceration. Which of the following actions should the nurse take?

A nurse is assisting in the care of a client who is in active labor and is to undergo an amniotomy. Which of the following actions should the nurse take? (Move the steps into the box, placing them in the order of performance. Use all the steps.)

A nurse is preparing a vitamin K injection to give to a newborn. The newborn's mother questions the purpose of the medication. Which of the following responses should the nurse make?

A nurse is reviewing client confidentiality with a group of newly licensed nurses. Which of the following situations should the nurse include as an example of a breach in confidentiality?

A nurse is caring for an adolescent who states, "I joined the track and field team, so I won't argue with my brothers anymore." The nurse should identify that the client is using which of the following defense mechanisms?

A nurse is reinforcing teaching about car seat safety with a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching?

A nurse is assisting in the care of a client who is 48 hr postpartum. The client states, "My baby won't stop crying even though I've changed her diaper and breastfed her." Which of the following statements should the nurse make?

A nurse is caring for a client who is 1 day postoperative following a total hip arthroplasty and is receiving heparin subcutaneously. Which of the following adverse effects of the medication should the nurse report to the provider?